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Mid-term Exam Practice Vocabulary 2 (Coding & Classification System)
Terms in this set (22)
This advises the coder that there is another place in the Alphabetic Index to which the coder must refer when the entries under consideration do not provide a code for the specific condition or procedure.
These advise the coder to look elsewhere before assigning a code.
Cross Reference Notes
These are used to further define, or give examples of, the content of the chapter, section, or category.
Identifies a code for a condition that is a manifestation of an underlying disease. The underlying condition must be sequenced before the code for the manifestation.
These enclose synonyms, alternative wordings, abbreviations, and explanatory phrases that provide additional information.
This word should be interpreted to mean "due to" when it appears in a code title or an instructional note.
These enclose nonessential modifiers
These notes are listed in alphabetic order, with the code number or code range shown in parenthesis. They indicate that a particular condition is not assigned to the code to which the note applies. The basic message of this type of notes is "code this condition elsewhere".
This advised the coder to refer to the main term of a condition.
This condition is not part of the condition represented by the code. It is acceptable to use both codes together if both conditions are present at the same time.
This provides the coder with a specific type of number. The coder must refer to that number in the Tabular List and select a code from the options provided there.
These are used in both inclusion and exclusion notes after an incomplete term to indicate that one or more of the modifiers from the list indented below the entry must be present in order for the statement to apply.
This indicates that the coder must refer to an alternative term.
A list of these words may be included under some codes. These words are some of the conditions that may be reported with those codes.
This note indicates that another code may be needed to include a complete statement of the condition.
Use Additional Code
These are in the Tabular List of Diseases and Injuries and provide information on usage in a specific section.
The physician provides specific findings but the code set does not list a specific code that described the diagnosis.
NEC- not elsewhere classified
The physician does not specify what the syndrome is. This is used only when neither the diagnostic statement nor the medical record provides information that permits classification to a more specific code.
NOS not otherwise specified
This word should be interpreted to mean either "and" or "or" when it appears in a title.
This note indicates two codes may be required to fully describe a condition.
These should never be used at the same time as the code above. These two conditions cannot occur together.
These include general notes, inclusion and exclusion notes, "code first" notes, "use additional code" notes, and "code also" notes.
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